Spacer for sling delivery system

ABSTRACT

The invention features systems, methods, and devices relating to delivering a sling to an anatomical site in the body of a patient.

RELATED APPLICATIONS

This application claims the benefit of and priority to provisionalpatent application Ser. No. 60/434,167, filed Dec. 17, 2002, andprovisional patent application Ser. No. 60/449,465, filed Feb. 24, 2003,the entirety of which is incorporated herein by reference.

TECHNICAL FIELD

The invention relates generally to systems, and related methods anddevices, for delivering an implant, such as a surgical sling, to ananatomical site in the body of a patient.

BACKGROUND OF THE INVENTION

Stress urinary incontinence (SUI) affects primarily women and isgenerally caused by two conditions, intrinsic sphincter deficiency (ISD)and hypermobility. These conditions may occur independently or incombination. In ISD, the urinary sphincter valve, located within theurethra, fails to close properly (coapt), causing urine to leak out ofthe urethra during stressful activity. Hypermobility is a condition inwhich the pelvic floor is distended, weakened, or damaged, causing thebladder neck and proximal urethra to rotate and descend in response toincreases in intra-abdominal pressure (e.g., due to sneezing, coughing,straining, etc.). The result is that there is an insufficient responsetime to promote urethral closure and, consequently, urine leakage and/orflow results.

Improved systems and methods for treating SUI are needed.

SUMMARY OF THE INVENTION

The invention addresses deficiencies of the prior art by providingdevices and methods for facilitating spacing away from a sling a sleeve,which at least partially encloses the sling. Such sling/sleeveconfigurations may be implanted into a patient's body, for example, forthe treatment of urinary incontinence. According to a particularembodiment, the sling/sleeve combination is delivered to a mid-urethrallocation of a patient. The methods and systems of the invention simplifycutting the sleeve at an intermediate location by a medical operator,while also reducing the likelihood of the medical operator inadvertentlycutting the sling. Once the sleeve is cut at an intermediate location,preferably via the vagina, the sleeve may be removed from the patient,for example, by pulling on sleeve ends. According to another advantage,the systems and methods of the invention space a intermediately locatedportion of the sling away from patient tissue, such as periurethraltissue, to make it easier for a medical operator to position thesling/sleeve combination without traumatizing the periurethral tissue.

The invention, which may be employed with any suitable sleeve/slingcombination, in various aspects, features a spacer for positioning awayfrom a portion of a sling a portion of a sleeve that at least partiallyencloses the sling; methods of making such a spacer; medical kitsincluding such a spacer; and methods of treating a damaged, weakened,sagging, herniated, or prolapsed portion of a patient's body using sucha spacer.

According to one embodiment of the invention, the spacer includes a tubehaving first and second ends and a lumen extending between the first andsecond ends. Preferably, the tube is formed into a V-shape, for example,by bending the tube at its midpoint such that the tube has first andsecond tube portions. When employed, the sleeve traverses through thelumen of the first and second tube portions and forms a sleeve bridgebetween the first and second tube ends across the open end of theV-shape. The tube can also include an aperture at the vertex of thefirst and second tube portions. The sleeve can pass, for example, intothe lumen in the first tube section via the aperture, out the first tubend, into the second tube end, through the second tube section and outthe aperture, thus forming the sleeve bridge between the first andsecond tube ends. The spacer can also include an anchoring mechanism foranchoring the sling in the tube. In some configurations, the anchoringmechanism includes a suture that passes through the lumen to form asuture bridge across the first and second tube ends. According to onefeature, the spacer includes a truss extending between the first andsecond tube portions.

In another embodiment, the spacer can include a sling engaging member.The sling engaging member facilitates the positioning of a portion of asling away from a portion of a sleeve. In one embodiment, the slingengaging member includes a slot for traversal by the sling. The slingslot can include an anchoring mechanism for holding the sling such thatthe sling does not move during placement of the sling at a site in thebody. The anchoring mechanism can be, for example, teeth such as taperedteeth or a cantilever beam such as a beam having an inverted T-shape.

The spacer may also include a sleeve engaging member. The sleeveengaging member facilitates the positioning of a portion of a sleeveaway from a portion of a sling. In one embodiment, the sleeve engagingmember includes a slot for traversal by the sleeve. The sleeve engagingmember serves to hold the sleeve in a position away from the sling sothat the medical operator can cut the sleeve without inadvertently alsocutting the sling.

In some configurations, the spacer also includes a tissue spacing memberfor spacing the sling away from a patient's tissue. As mentioned above,such spacing makes it easier for a medical operator to position thesling during delivery. Preferably the tissue spacing member has aconcave surface for supporting tissue, such as periurethral tissue at amid-urethral location in a patient's body.

The spacer of the invention may include an indicator for indicating tothe medical operator a direction in which the spacer is to be removed.The indicator can also include a handle for facilitating spacer removal.In one configuration, the indicator is shaped like an arrowhead, withthe tip of the arrowhead indicting the direction of removable. In otherconfigurations, the arrowhead is large enough to form a handle tofacilitate spacer removal.

According to a further embodiment, the spacer of the invention includesa receptacle for traversal by a portion of the sleeve. The spacer mayalso include an insert for mating within the receptacle and holding theportion of the sleeve in place within the receptacle. The receptacle maybe of any suitable shape. Preferably, it is substantially U-shaped andthe insert is appropriately shaped for mating engagement with thereceptacle.

In some embodiments, the spacer includes an elongated shaft extendingbetween the sleeve engaging member and the sling engaging member. Thepresence of an elongated shaft in the spacer is advantageous as itfacilitates spacing of the sleeve away from the sling and has the addedfeature of making it easier for a medical operator to remove the spacerfrom the patient's body following sling placement. In one embodiment,the elongated shaft includes a proximal end and a distal end and achannel extending between the proximal end and the distal end. The slingis positioned at the distal end of the elongated shaft and the sleeve ispassed through the channel to the proximal end where a sleeve engagingmember holds the sleeve in place, and/or forms a sleeve bridge tofacilitate cutting of the sleeve by a medical operator.

In an alternative configuration the sling engaging member includes a pinextending from the spacer. In one such configuration, the spacerincludes a first elongated shaft extending between the pin and thesleeve engaging member and a second elongated shaft extending betweenthe pin and the sleeve engaging member, and the first and secondelongated members each include a channel for passage of the sleeve. Thedistal ends of the elongated shafts further include a sleeve engagingmember, for example, for holding the sleeve in place and/or for forminga sleeve bridge for facilitating cutting of the sleeve by a medicaloperator.

In another aspect, the invention provides a sling delivery systemincluding a sling assembly and a spacer, as described above. The slingassembly includes an elongated sling (i.e., a mesh sling) and a sleeveenclosing at least a portion of the sling. For example, a sling systemcan include a sling, a sleeve covering at least a portion of the sling,and a spacer, wherein the sleeve comprises first and second sides, thefirst side having first and second slit-shaped apertures intermediatelylocated between first and second ends of the sleeve, the sling threadsout of the sleeve through the first slit-shaped aperture and back intothe sleeve through the second slit-shaped aperture creating a mid-lengthsleeve loop, and the spacer is positioned to space the sling away fromthe mid-length sleeve loop. In this embodiment, the spacer can be atube, such as a substantially flat tube which includes an aperture forsighting a cutting line through the spacer and sleeve loop to separatethe sleeve into portions that may be removed from about the sling, andwherein the sleeve loop is partially secured within the interior of thetube.

In one embodiment of this aspect of the invention, the sleeve includesfirst and second ends and the spacer is positioned intermediate to thefirst and second ends. In another embodiment, the sling includes firstand second sides, the sleeve includes first and second sides, and thespacer is disposed between the second side of the sling and the secondside of the sleeve. According to various configurations, thesling/sleeve combination may terminate in any suitable fashion.

The foregoing and other objects, aspects, features, and advantages ofthe invention will become more apparent from the following description.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, like reference characters generally refer to the sameparts throughout the different views. Also, the drawings are notnecessarily to scale, emphasis instead generally being placed uponillustrating the principles of the invention.

FIG. 1 depicts a perspective side view of a spacer according to anillustrative embodiment of the invention employed with an exemplarysling assembly section.

FIG. 2 depicts a perspective side view of a spacer according to anotherillustrative embodiment of the invention employed with an exemplarysling assembly section.

FIG. 3A depicts a perspective side view of a spacer according to anotherillustrative embodiment of the invention employed with an exemplarysling assembly section.

FIG. 3B depicts a perspective front view of the spacer and slingassembly section of FIG. 3A.

FIG. 4A depicts a perspective top view of a spacer according to anotherillustrative embodiment of the invention.

FIG. 4B depicts a perspective bottom view of the spacer of FIG. 4A.

FIG. 4C depicts a perspective top view of the spacer of FIG. 4A employedwith an exemplary sling assembly section according to an illustrativeembodiment of the invention.

FIG. 4D depicts a perspective bottom view of the illustrative spacer andsling assembly section of FIG. 4C.

FIG. 4E depicts a perspective side view of the illustrative spacer andsling assembly section of FIG. 4C.

FIG. 5 depicts a perspective side view of the spacer and sling assemblysection of FIGS. 4C-4E employing according to another illustrativeembodiment of the invention.

FIG. 6A depicts a perspective side view of the spacer and sling assemblysection of FIG. 4C, positioned adjacent the urethra of a patient.

FIG. 6B depicts a perspective side view of the illustrative spacer andsling assembly section of FIG. 6A after the sleeve bridge is cut.

FIG. 7A depicts a perspective top view of a spacer according to anotherillustrative embodiment of the invention.

FIG. 7B depicts a perspective top view of the illustrative spacer ofFIG. 7A employed with an exemplary sling assembly section according toan illustrative embodiment of the invention.

FIG. 8A depicts a perspective front view of a spacer according toanother illustrative embodiment of the invention.

FIG. 8B depicts a perspective side view of the illustrative spacer ofFIG. 8A employed with an exemplary sling assembly section according toan illustrative embodiment of the invention.

FIG. 9 depicts a perspective side view of a spacer according to anotherillustrative embodiment of the invention.

FIG. 10A depicts a perspective side view of a spacer according toanother illustrative embodiment of the invention.

FIG. 10B depicts a plan view of the illustrative spacer of FIG. 10Aemployed with an exemplary sling assembly section according to anillustrative embodiment of the invention.

FIG. 11A depicts a perspective top view of a spacer according to anotherillustrative embodiment of the invention.

FIG. 11B depicts a perspective side view of the illustrative spacer ofFIG. 11A, bent at its mid-point according to illustrative embodiment ofthe invention.

FIG. 11C depicts a perspective side view of the illustrative spacer ofFIG. 10B employed with an exemplary sling assembly section according toan illustrative embodiment of the invention.

FIG. 11D depicts a perspective side view of an anchoring mechanismaccording to an illustrative embodiment of the invention employed withthe illustrative spacer and sling assembly of FIG. 11C.

FIG. 11E depicts a bottom view of the spacer of FIG. 11A further formedto include a truss according to an illustrative embodiment of theinvention.

FIG. 11F depicts a perspective top view of the illustrative spacer ofFIG. 10E.

FIG. 11G depicts a perspective side view of the illustrative spacer ofFIG. 10F, bent at its mid-point according to another illustrativeembodiment of the invention.

FIG. 11H depicts a perspective side view of the illustrative spacer ofFIG. 10G employed with an exemplary sling assembly section according toan illustrative embodiment of the invention.

FIG. 12 depicts a perspective side view of a spacer and a sling assemblyaccording to an illustrative embodiment of the invention.

FIG. 13 depicts a perspective side view of the spacer and sling assemblyof FIG. 12 where the sling ends are held in the spacer.

FIG. 14 depicts a perspective side view of the spacer and sling assemblyof FIG. 12 according to a further illustrative embodiment of theinvention.

FIG. 15 depicts an approach to removing the spacer of FIG. 12 accordingto an illustrative embodiment of the invention.

ILLUSTRATIVE DESCRIPTION OF THE INVENTION

In general, the invention pertains to systems, methods, and devicesrelating to delivering a sling to an anatomical site in the body of apatient, for example, the periurethral tissues of the patient in thetreatment of female urinary incontinence. More particularly, theinvention is directed to various configurations of spacers for spacingaway from the sling at least a portion of a sleeve that at leastpartially encloses the sling. By spacing a portion of the sleeve awayfrom the sling, the spacers of the invention enable a medical operatorto more easily cut the sleeve, without damaging the sling, so that thesleeve may be removed from a patient's body, while leaving the sling inplace. Another feature of some spacer configurations of the invention isthat the spacer acts to space a portion of the sling away from patienttissue, for example, periurethral tissue. By spacing a portion of thesling away from the patient tissue, the spacer of the invention makes iteasier for the medical operator to position the sling withouttraumatizing patient tissue that would otherwise rub against the slingduring positioning. As a preliminary matter it should be noted that thevarious illustrative spacer configurations discussed in further detailbelow may be employed with any suitable sling/sleeve configuration. Byway of example, the spacers of the invention may be employed withsleeves having one or more apertures. They may also be employed withsleeves having a generally unitary construction or alternatively, withsleeves formed from multiple discrete sections. Without limitation,exemplary sling/sleeve configurations that may be operable withillustrative embodiments of the invention may be found in U.S. patentapplication entitled Medical Slings, to Rao et al, Ser. No. 10/641,470,pending; U.S. patent application entitled Medical Slings, to Chu, Ser.No. 10/641,192, pending; U.S. provisional patent application entitledSurgical Slings, to Li et al, Ser. No. 60/495,439, pending; U.S. patentapplication entitled Systems, Methods and Devices relating to Deliveryof Medical Implants, to Chu et al., Ser. Nos. 10/642,395, pending,10/642,397, abandoned 10/642,365, pending, and 10/641,487, pending U.S.patent application entitled Medical Implant, to Chu et al., Ser. No.10/640,838, pending; U.S. provisional patent application Ser. No.60/403,555; U.S. provisional patent application Ser. No. 60/465,722;U.S. patent application Ser. No. 10/460,112, now U.S. Pat. No.7,070,558; and U.S. patent application Ser. No. 09/096,983, now U.S.Pat. No. 6,100,821, the entire contents of which are incorporated hereinby reference.

As another preliminary matter, the ends of the slings or sleevesemployed may terminate in any suitable configurations or structures suchas loops, for example, apertures, male and female connectors, guidetubes and the like. Some exemplary sling/sleeve terminationconfigurations and structures are disclosed in U.S. patent applicationSer. No. 10/325,125; U.S. provisional patent application Ser. No.60/418,827; U.S. provisional patent application Ser. No. 60/418,642;U.S. provisional patent application Ser. No. 60/434,167; and U.S.provisional patent application Ser. No. 60/403,555; the disclosures ofwhich are incorporated herein by reference.

As a further preliminary matter, it should be noted that the variousillustrative spacer configurations may be employed with any suitablesling delivery system. By way of example, the spacers of the inventionmay be employed with any sling/sleeve configurations and deliverysystems appropriate for treating urinary incontinence. Such deliverysystems include, for example, those delivery systems configured forsupra-pubic, pre-pubic, transvaginal or transobturator approaches.Without limitation, exemplary delivery systems, slings, slingattachments and methodologies that may be employed in combination withthe spacers of the invention can be found in U.S. patent applicationSer. No. 10/093,498; U.S. patent application Ser. No. 10/093,398; U.S.patent application Ser. No. 10/093,450; U.S. patent application Ser. No.10/094,371; U.S. patent application Ser. No. 10/094,352; U.S. patentapplication Ser. No. 10/093,424; U.S. provisional patent applicationSer. No. 60/403,555; U.S. patent application Ser. No. 09/916,983; U.S.provisional patent application Ser. No. 60/465,722; U.S. provisionalpatent application Ser. No. 60/418,827; U.S. provisional patentapplication Ser. No. 60/418,642; U.S. provisional patent applicationSer. No. 60/274,843; U.S. provisional patent application Ser. No.60/286,863; and U.S. provisional patent application Ser. No. 60/434,167,the disclosures of which are incorporated herein by reference.

Turning now to illustrative embodiments of the invention, FIG. 1 depictsa perspective side view of a spacer 102 according to an illustrativeembodiment of the invention employed with an exemplary sling assemblysection 100. As depicted, the sling assembly 100 includes a mesh sling104 partially enclosed by a sleeve 106. Although, the sleeve 106 may beany suitable sleeve, illustratively it is shown as having a first sleevewall 108 and a second sleeve wall 110, with the mesh sling 104 locatedbetween the first 108 and second 110 sleeve walls. The first sleeve wall108 includes a discontinuity forming a gap 112 exposing an intermediateportion 114 of the mesh sling 104. The particular spacer 102 in thisembodiment is generally rectangular in shape and spaces anintermediately located portion 116 of the sleeve wall 110 away from theintermediate sling portion 114. The spacer 102 is positioned to create aloop 118 in the intermediate portion 116 of the sleeve wall 110. Asdescribed below in further detail with regard to FIGS. 4-11, the spacer102 can be operatively engaged with the intermediate portion 116 of thesleeve wall 110 in a variety of ways. By way of example, the spacer 102may include any number of slots, channels or protuberances to engage thesleeve wall 110. Alternatively, the spacer 102 can be bonded to orinterconnected via suture with the sleeve wall 110.

In operation, once the sling assembly 100 is positioned within the bodyof a patient, for example under a patient's mid-urethra, a medicaloperator can insert a pair of scissors into the loop 118 to cut thesleeve 106, without risking accidentally cutting the sling 104. With thesleeve 106 so cut, the sleeve ends 120 and 122 may be pulled to removethe sleeve 106 from the patient's body, while leaving the sling 104 inplace. The spacer 102 may be removed, for example, via the patient'svagina.

FIG. 2 depicts a perspective side view of a spacer 202 according toanother illustrative embodiment of the invention employed with anexemplary sling assembly section 200. The illustrative spacer 202 ofFIG. 2 is substantially cylindrical in shape. In a similar fashion toFIG. 1, the sling assembly 200 includes a mesh sling 204 partiallyenclosed by a sleeve 206. As in the case of the sleeve 106, the sleeve206 may be any suitable sleeve. Illustratively, it is shown as having afirst sleeve wall 208 and a second sleeve wall 210, with the mesh sling204 located between the first 208 and second 210 sleeve walls. The firstsleeve wall 208 includes a discontinuity forming a gap 212 exposing anintermediate portion 214 of the mesh sling 204. The particular spacer202 is generally cylindrical in shape and spaces an intermediatelylocated portion 216 of the sleeve wall 210 away from the intermediatesling portion 214. The spacer 202 is positioned to create a loop 218 inthe intermediate portion 216 of the sleeve wall 210. As in the case ofthe embodiment of FIG. 1, and as described below in further detail withregard to FIGS. 4-11, the spacer 202 can be operatively engaged with theintermediate portion 216 of the sleeve wall 210 in a variety of ways. Byway of example, the spacer 202 may include any number of slots, channelsor protuberances to engage the sleeve wall 210. Alternatively, thespacer 202 can be bonded to or interconnected via suture with the sleevewall 210. In some illustrative configurations, the spacer 202 isflattened to form a friction based attachment to a portion of theintermediate portion 216 of the sleeve wall 210.

Once the sling assembly 200 is positioned within the body of a patient,for example under a patient's mid-urethra, a medical operator can cutthrough the spacer 202 and thus, cut through the intermediate portion216 of the sleeve wall 210, without risking accidentally cutting thesling 204. As in the case of the embodiment of FIG. 1, with the sleeve206 so cut, the sleeve ends 220 and 222 may be pulled to remove thesleeve 206 from the patient's body, while leaving the sling 204 inplace. The spacer 202 may be removed, for example, via the patient'svagina.

FIG. 3A depicts a perspective side view of a spacer 302 according toanother illustrative embodiment of the invention employed with anexemplary sling assembly section 300, and FIG. 3B depicts a perspectivefront view of the spacer 302 and sling assembly section 300 of FIG. 3A.Referring to FIGS. 3A and 3B, in a similar fashion to the embodiments ofFIGS. 1 and 2, the sling assembly 300 includes a mesh sling 304partially enclosed by a sleeve 306. As in the case of the sleeve 206,the sleeve 306 may be any suitable sleeve. Illustratively, it is shownas having a first sleeve wall 308 and a second sleeve wall 310, with themesh sling 304 located between the first 308 and second 310 sleevewalls. The first sleeve wall 308 includes a discontinuity forming a gap312 exposing an intermediate portion 314 of the mesh sling 304.

The particular spacer 302 is generally flat in shape and includes first303 and second 305 sides between which an intermediately located portion316 (not visible) of the sleeve wall 310 is sandwiched and spaced awayfrom the intermediate sling portion 314. According to the illustrativeembodiment, the tab spacer 302 is closed along its top edges 307 and 309and open along its intermediate edges 311 and 313. The bottom edge 315is left open until after the intermediately located portion 316 of thesleeve wall 310 is inserted in between the first 303 and second 305sides of the spacer 302. Subsequent to insertion of the intermediateportion 316, the bottom edge 315 of the spacer 302 is bonded, forexample, using heat or glue, together and to that portion of theintermediate portion 316 of the sleeve wall 310 located near the bottomedge 315 of the spacer 302. With the bottom edge 315 50 bonded, thespacer 302 may be removed by cutting from one intermediate edge 311 tothe other intermediate edge 313, and then sliding the remaining portionof the spacer 302 off the intermediate portion 316 of the sleeve wall310. The illustrative spacer 302 also includes an aperture 317, whichindicates a location for making the cut between the intermediate edges311 and 313. The aperture 317 also enables a person to view theintermediate portion 316 of the sleeve wall 310 to verify properinstallation into the spacer 302.

Once the sling assembly 300 is positioned within the body of a patient,for example under a patient's mid-urethra, a medical operator can cutthrough the spacer 302 as described above and thus, cut through theintermediate portion 316 of the sleeve wall 310, without riskingaccidentally cutting the sling 304. As in the case of the embodiment ofFIGS. 1 and 2, with the sleeve 306 so cut, the sleeve ends 320 and 322may be pulled to remove the sleeve 306 from the patient's body, whileleaving the sling 304 in place. The spacer 302 may be removed, forexample, via the patient's vagina.

FIG. 4A depicts a perspective top view of a spacer 400 according toanother illustrative embodiment of the invention, and FIG. 4B depicts aperspective bottom view of the spacer 400 of FIG. 4A. FIGS. 4C-4E depictvarious views of the spacer 400 employed with an exemplary slingassembly 402. Referring to FIGS. 4A-4D, the spacer 400 includes a firstside 404; a second side 408; a top side 410; a bottom side 412; a frontside 414; and a back side 416 (i.e., a side that is closest to anoperator of a delivery system). The spacer 400 also includes a slingengaging member, 418, formed as a sling slot positioned underneath thetop side 410, and a sleeve engaging member 420, formed as two sleeveslots 420A and 420B positioned on the first side 404 of the spacer 400,and two sleeve slots 420C and 420D positioned on the second side 408 ofthe spacer 400. Alternatively, the spacer 400 may include any number ofsides with any number of sling engaging members 418 or sleeve engagingmembers 420 positioned on any side.

The illustrative spacer 400 is constructed of a rigid medical gradeplastic material or, alternatively, of other suitable rigid materials.However, in alternative embodiments, the spacer 400 may be formed frommore flexible suitable materials. The top side 410 of the spacer 400 canserve as a tissue spacing member 422 for spacing the sling 403 of thesling assembly 402 away from the patient's tissue.

The illustrative spacer 400 also includes an indicator 424, whichindicates the direction in which the spacer 400 should be removedfollowing implantation of the mesh sling 403 at an anatomical site inthe patient's body. The indicator 424, optionally, includes or is sizedbig enough to be used as a handle. Such a handle may be located on anyof the sides of the spacer 400.

Referring particularly to FIGS. 4C-4E, the spacer 400 is depicted invarious views employed with the sling assembly section 402. As in thecase of previously described embodiments, the sling assembly 402includes a mesh sling 403 partially enclosed by a sleeve 405. As in thecase of the sleeves 106, 206 and 306, the sleeve 405 may be any suitablesleeve. Illustratively, it is shown as having a first sleeve wall 407and a second sleeve wall 409, with the mesh sling 403 located betweenthe first 407 and second 409 sleeve walls. Preferably, the first sleevewall includes a discontinuity forming a gap exposing an intermediateportion of the mesh sling 403.

As depicted, the spacer 400 includes a tissue spacing member 422 at itstop side 410. The height 426 of the tissue spacing member 422 may bevaried to suit a particular clinical application. When the top side 410of the spacer 400 is placed under a patient's urethra, as explainedbelow with respect to FIGS. 5A and 5B, the height 426 of the tissuespacing member 422 governs the distance between an intermediate portion428 of the mesh sling 403 and the patient's tissue, for example, theperiurethral tissue. The tissue spacing member 422 can be any shape, forexample, convex or concave, such that the spacer 400 easily fits under apatient's urethra, as explained below.

As shown in FIG. 4E, the sling engaging member 416 of the illustrativespacer 400 includes both step teeth 430A and 430B and spiral teeth 432Aand 432B, which function as anchoring mechanisms for engaging theintermediate portion 428 of the mesh sling 403 when the mesh sling 403is tensioned. When no tension is applied to the mesh sling 403 (i.e.,when the operator has not yet begun to cut and remove the sleeve 405from the patient's body), the mesh sling 403 sits loosely in the slingengaging member 418, without engagement by either the step teeth 430Aand 430B or the spiral teeth 432A and 432B. In one embodiment, both thestep teeth 430A and 430B and the spiral teeth 432A and 432B are taperedtoward the front side 414 of the spacer 400. When the medical operatoris ready to remove the spacer 400 from the sling assembly 402, the taperof the step teeth 430A and 430B and the spiral teeth 432A and 432Bfacilitate the process.

The illustrative spacer 400 also includes a receptacle 434 having aninner wall 436, which forms, for example, an archway 438, which issubstantially U-shaped. Alternatively, the receptacle 434 may form anyother suitable geometrical shape, including, but not limited to, anangular (e.g., an open ended polygon, such as a rectangle or triangle)or curved (e.g. substantially semicircular) shape. As depicted, thesecond sleeve wall 409, or alternatively, both the first sleeve wall 407and the second sleeve wall 409, thread through the sleeve engagingmembers 420A-420D. The sleeve 403 forms a sleeve bridge 440 at the baseof the archway 434, between the sleeve slots 420B and 420C. In otherwords, the spacer 400 distances the sleeve bridge 440 away from the meshsling 403, thereby enabling a medical operator to cut the sleeve bridge440 ut, without inadvertently also cutting the mesh sling 403.

FIG. 5 depicts a perspective side view of the spacer 400 and slingassembly section 402 of FIGS. 4C-4E employing an insert 442 according toanother illustrative embodiment of the invention. The insert 442, forexample, a plug, for mating within the receptacle 434 and holding aportion of the sleeve 405 in place within the receptacle 434. The spacer400 and the sling assembly 402 can be preassembled before its placementin the patient's body. Once the insert 442 is removed, the sleeve bridge440 may be cut thereby creating sleeve parts 444A and 444B, without riskof the mesh sling 403 also being inadvertently cut. Alternatively, priorto insertion of the sling assembly in the patient, the sleeve 405 can becut to form the sleeve parts 444A and 444B. The plug 442 is then placedwithin the receptacle 434 to hold the sleeve parts 444A and 444B inplace against the inner wall 436. So assembled, the sling assembly 402and spacer 400 can then be delivered to the medical operator. Becausethe medical operator only has to remove the plug 442 from within thereceptacle 434 of the spacer 400, and no sleeve cutting is requiredduring sling delivery, the risk of damaging the sling 403, for example,from inadvertent cutting, during placement is reduced.

FIG. 6A depicts a perspective side view of the spacer 400 and slingassembly section 402 of FIG. 4C, positioned adjacent the urethra 600 ofa patient, and FIG. 6B depicts a perspective side view of theillustrative spacer 400 and sling assembly section 402 of FIG. 6A afterthe sleeve bridge is cut, for example, subsequent to remove of theinsert 442. The removal of the insert 442 and cutting of the sleeve 405causes the sleeve parts 444A and 444B to hang free in the archway 434.Alternatively, the physician may leave the plug 442 in place and cut thesleeve 405 at a point, for example, between the sleeve slots 420A and420B, thereby creating the sleeve part 444A, and at a point between thesleeve slots 420C and 420D, thereby creating the sleeve part 444B. As inthe case of the embodiments of FIGS. 1-3B, by grasping the sleeve ends602 and 604 and pulling, the medical operator can then remove the sleeve405 from the patient's body, for example, through a surgical site at theabdominal wall, leaving the mesh sling 403 and the spacer 400 in placein the patient's body. The spacer 400 can then be removed, for example,via the patient's vagina.

Referring also to FIGS. 4A and 4B, during the removal of the sleeve 405from the patient's body, the friction between the sleeve 405 and themesh sling 403 causes the mid-length portion 428 of the mesh sling 403to tension against step teeth 430A and 430B and spiral teeth 432A and432B. As such, the spacer 400 prevents the mid-length portion 428 of themesh sling 403 from moving beyond the mesh slot 418 during the sleeve405 removal process. In other words, the mid-length portion 428 of themesh sling 403 remains, throughout the sleeve removal process, in themesh slot 418, under the top side 410 of the spacer 400, and,consequently, directly below the patient's urethra 600.

FIG. 7A depicts a perspective top view of a spacer 700 according toanother illustrative embodiment of the invention, and FIG. 7B depicts aperspective top view of the illustrative spacer 700 of FIG. 7A employedwith an exemplary sling assembly section 702. Referring to FIGS. 7A and7B, the illustrative spacer 700 includes a sling engaging member 704having a cantilever beam 706 as an anchoring mechanism. In the depictedembodiment, the cantilever beam 706 has an inverted T-shape.Alternatively, the cantilever beam 706 may assume other shapes. Thecantilever beam 706, in a similar fashion to the step teeth 430A an 430Band the spiral teeth 432A and 432B of the spacer of FIGS. 4A-6B, engagesa mid-length portion 708 of a mesh sling 710 when the mesh sling 710 istensioned. The spacer 700 also includes sleeve engaging members 712A and712B, which function substantially like the sleeve engaging members 420Aand 420D, respectively, of the spacer 400 of FIG. 4.

Referring particularly to FIG. 7B, the second sleeve wall 712, or,alternatively, both the first sleeve wall 714 and the second sleeve wall712, loop under a base 716 of the first side 718 of the spacer 700 andunder a base 720 of the second side 722 of the spacer 700, rather thanthrough sleeve engaging members, such as the sling engaging members 432Band 432 c of the spacer 400 of FIG. 4, to form a sleeve bridge 724. Inan alternative embodiment, the second sleeve wall 712, or,alternatively, both the first sleeve wall 714 and the second sleeve wall712, may be disconnected at a point between the base 716 and the base720 and held in place against the inner wall 726 of the archway 728 by aplug, such as the plug 442 of FIG. 5. As illustrated, the intermediateportion 708 of the mesh sling 710 is placed in the sling engaging member704 and loops under the cantilever beam 706.

In operation, as the sleeve 730 is pulled off the mesh sling 710,intermediate portion 708 of the mesh sling 710 tensions and deflects thecantilever beam 706 into an opposing face (e.g., a face 732), therebypinning the intermediate portion 708 of the mesh sling 710 between thecantilever beam 706 and the face 732. Following removal of the sleeve730 from the patient's body, the cantilever beam 706 relaxes, therebyallowing for the removal of the intermediate portion 708 of the meshsling 710 from the mesh slot 704.

FIG. 8A depicts a perspective front view of a spacer 800 according toanother illustrative embodiment of the invention, and FIG. 8B depicts aperspective side view of the spacer 800 of FIG. 8A employed with anexemplary sling assembly section 802. The spacer 800 includes anelongated shaft member 804 extending between a sling engaging member 806and a sleeve engaging member 808. The elongated shaft member 804 has aproximal end 824 and a distal end 826 and includes two walls 810 and 812extending along its length and forming a channel 814 from the proximalend 824 to the distal end 826 for traversal by an intermediate portion816 of the sleeve wall 818. In one embodiment, the sleeve engagingmember 808 may be, for example, U-shaped for forming a sleeve bridge822, such as the sleeve bridge 440 of FIG. 6A, across its terminal end820 for facilitating cutting of the second sleeve wall 818 by a medicaloperator. Alternatively, the sleeve engaging member 808 may be anysuitable shape such as, for example, V-shaped or rectangularly-shaped.

With the spacer 800 and the sling assembly 802 engaged, the intermediateportion 816 of the second sleeve wall 818, or, alternatively, both thefirst sleeve wall 817 and the second sleeve wall 818, thread through thechannel 814 of the elongated shaft member 804 and loop over span 820 ofthe U-shaped sleeve engaging member 808 to form the sleeve bridge 822,as indicated by arrow 828. The sleeve ends 830 and 832 then threadthrough the sleeve slots 806A and 806B, respectively, and functionsimilarly to the sleeve slots 712A and 712B of FIGS. 7A and 7B. In asimilar fashion to operation of the mesh slot 704 of the spacer 700 ofFIGS. 7A and 7B, the intermediate portion 834 of the mesh sling 836threads through the mesh slot 838.

One advantage of the spacer 800 is that the elongated shaft member 804presents the sleeve bridge 822 to the medical operator at a greaterdistance from the mesh sling 836 than do the previously describedembodiments. This increased distance further simplifies the process ofcutting the sleeve bridge 822, and further eases the process of removingthe sleeve from the patient's body. Moreover, the elongated shaft member804 makes the task of removing the spacer 800 from the patient's bodyeasier, as the medical operator need not reach as far into the patient'sbody to grasp the spacer 800 and remove it.

FIG. 9 is a perspective view of an spacer 900 having a similarconfiguration to the illustrative spacer 800 of FIGS. 8A and 8B, butincluding an elongated shaft member 902 bent at an angle 904, of up toabout 90 degrees, relative to the top side 906 of the spacer 900. Anadvantage of this configuration is that positions the sleeve engagingmember 908 to ease the procedure of cutting the sleeve bridge duringremoval of the sleeve from the patient's body.

FIG. 10A depicts a perspective side view of a spacer 1000 according toanother illustrative embodiment of the invention, and FIG. 10B depicts aplan view of the spacer 1000 of FIG. 10A employed with an exemplarysling assembly section 1002. As shown, the spacer 1000 includes a shaft1004, an extension 1006, and a pin 1008 extending from the spacer 1000.The shaft 1004 includes a proximal end 1010, a distal end 1012, andfirst 1014 and second 1016 walls forming a channel 1018 extending fromthe proximal end 1010 to the distal end 1012. The first wall 1014includes a first face 1020 and the second wall 1016 has a second face1122. The spacer 1000 also includes first 1024 and second 1026 sleeveengaging members. As depicted, a first sleeve slot 1028 passes from thethrough the first 1014 and second 1016 walls across the channel 1018.The first sleeve engaging member 1024 extends at an angle 1032 from abase face 1020 of the wall 1014. Similarly, he second sleeve engagingmember 1026 extends at an angle 1034 from the face 1022 of the secondwall 1016. Preferably, the angles 1032 and 1034 are substantially equal.In some configurations, the angles 1042 and 1034 are both about 180degrees. In another embodiment, the sleeve engaging members 1024 and1026 are curved, rather than angled, with respect to the first 1014 andsecond 1016 walls. In another alternative embodiment, the sleeveengaging members 1024 and 1026 form a substantially V-shape. Theextension 1006 extends distally from the distal end 1012 of the shaft1004. The pin 1008 is fixed to and extends substantially orthogonallyfrom the extension 1006.

Referring particularly to FIG. 10B, the second sleeve surface 1042, or,alternatively, both the first sleeve surface 1040 and the second sleevesurface 1042 thread across a top side 1040 of the first wall 1014,through the channel 1018, through the first sleeve slot 1028, across abase 1054 of the first sleeve engaging member 1024, across a base 1056of the second sleeve engaging member 1026, through the second sleeveslot 1030, back through the channel 1018, and across a top side 1058 ofthe second wall 1016. In this way, the second sleeve wall 1042, or,alternatively, both first sleeve wall 1040 and the second sleeve wall1042, form a sleeve bridge 1060 between the first sleeve engaging member1024 and the second sleeve engaging member 1024. Preferably, the pin1008 passes through the weave of an intermediate portion 1048 of themesh sling 1046, so as to act as an anchoring mechanism that engages theintermediate portion 1048 of the mesh sling 1046. As such, the pin 1008prevents movement of the intermediate portion 1046 of the mesh sling1048 when the mesh sling 1048 is tensioned during removal of the sleeve1044 from the patient's body.

FIG. 11A depicts a perspective top view of a spacer 1100 according toanother illustrative embodiment of the invention. The spacer 1100 isgenerally tubular in shape and includes a wall 1101 defining a lumen1102 extending between first 1104 and second 1106 apertures. As depictedin FIG. 11A, the spacer 1100 includes a slot shaped aperture 1108 formedat an intermediate location in the tube wall 1101 between the first 1104and second 1106 apertures. The aperture 1108 effectively divides thespacer 1100 along the center line 1110 into two substantially equalhalves 1100 a and 1100 b.

FIG. 11B depicts a perspective side view of the illustrative spacer 1100of FIG. 11A, bent at its mid-line 1110 according to illustrativeembodiment of the invention. So bent, the two spacer halves 1100 a and1100 b are formed into a substantially V-shape, with a vertex at 1112and one leg including a first lumen section 1102 a and the other legincluding the second lumen section 1102 b. In an alternativeillustrative embodiment, the first and second spacer halves 1100 a and1100 b may form a substantially U-shaped or rectangularly-shaped spacer.In other illustrative embodiments, the tubular shape of the spacer 1100may be flattened, with the aperture 1108 formed on one of the resultingsides. As in the case of the previously discussed spacer embodiments,the spacer 1100 may be made of a polymer or other suitable material.

FIG. 11C depicts a perspective side view of the spacer 1100, bent inaccord with the illustrative embodiment of FIG. 10B, employed with anexemplary sling assembly section 1114. The sling assembly 1114 includesa mesh sling 1116, at least partially enclosed by a sleeve 1118. Asdepicted, the second sleeve surface 1122, or, alternatively, both thefirst sleeve surface 1120 and the second sleeve surface 1122, passthrough the aperture 1108 at the vertex 1112. The second sleeve surface1122 passes through the first lumen section 1102 a, through the firstaperture 1104, across and into the second aperture 1106, through thesecond lumen section 1102 b and back out the aperture 1108 to form asleeve bridge 1130 between the first aperture 1104 and the secondaperture 1106.

FIG. 11D depicts a perspective side view of the spacer 1100 and slingassembly 1114 configuration of FIG. 11C employing and anchoringmechanism according to an illustrative embodiment of the invention. Inthe embodiment of FIG. 11D, the anchoring mechanism includes a suture1134 threaded through the weave of an intermediate portion 1124 of themesh sling 1116, so as to engage the intermediate portion 1124. Thesuture 1134, in a similar fashion to the sleeve wall 1122, passesthrough the aperture 1108 and the first 1102 a and second 1102 b lumensections, and forms a suture bridge 1134. As such, the suture 1132prevents movement of the intermediate portion 1124 of the mesh sling1116 when the mesh sling 1116 is tensioned during removal of the sleeve1118 from the patient's body.

FIG. 11E depicts a bottom view of the spacer 1100 further formed toinclude a truss 1136 according to an illustrative embodiment of theinvention. FIG. 11F depicts a perspective top view of the spacer 1100 ofFIG. 10E. FIG. 11G depicts a perspective side view of the spacer 1100 ofFIG. 10E bent along its mid-line 1110, according to further illustrativeembodiment of the invention. Referring to FIGS. 11E-11G, first 1138 andsecond 1140 substantially parallel slits are formed in the wall 1101 toform the truss 1136 to be substantially symmetrical about the centerline 1110. The spacer 1100 may or may not be flattened during thisprocess. As depicted in FIGS. 11F and 11G, the spacer 1100 is thenfolded into the V-shape of FIG. 11B, causing the truss 1136 to fold outof and away from the wall 1101, thereby creating a slot 1142, betweenslits 1138 and 1140.

FIG. 11H depicts the spacer 1100 configured as depicted in FIG. G andemployed with the exemplary sling assembly 1114. In the illustrativeembodiment of FIG. 11H, the sleeve 1118 traverses the spacer 1100 toform the sleeve bridge 1130 in the same manner as described above withrespect to the embodiment of FIG. 11C. Additionally, the intermediateportion 1124 of the sling 1116 passes through the slot-shaped aperture1108 out the aperture 1142 in the first spacer half 1100 a and rests ontop of the truss 1136. An anchoring mechanism, for example, an anchortube 1150, may be used to secure the intermediate mesh portion 1124against the truss 1136. As indicated by arrow 1152, the anchor tube 1150is placed between the intermediate sling portion 1124 and the wall 1101.In the illustrative embodiment, an lower portion 1154 of the outerof theanchor tube 1150 pins the intermediate sling portion 1124 against thetruss 1136, while an upper portion 1156 of the outer surface of theanchor tube 1150 rests against the outer wall 1101 of the spacer 1100near the vertex 1112. As such, the anchor tube 1150 prevents movement ofthe intermediate sling portion 1124 when the mesh sling 1116 istensioned during removal of the sleeve 1118 from the patient's body.

The truss 1136, in this embodiment of the invention, also prevents thespacer halves 1101 a and 1101 b from moving towards one another when thesleeve 1116 is tensioned to place the spacer 1100 under the patient'surethra. Moreover, as illustrated, this embodiment of the inventionallows for a greater amount of slack in the intermediate sling portion1124.

FIG. 12 depicts the sling assembly 1200 including two sleeves 1202 and1204 employed with a tubular spacer 1206 according to anotherillustrative embodiment of the invention. In this embodiment, the sleevetails 1208 and 1210 extend from the proximal ends 1212 and 1214 of thesleeves 1202 and 1204, respectively, and fit into the tubular spacer1206. In the illustrative embodiment, the tubular spacer 1206 issubstantially cylindrical. Alternatively, the tubular spacer 1206 can beflattened. The tubular spacer 1206 can be formed from any suitablematerial, such as a rigid or tearable polymer material.

FIG. 13 depicts a further illustrative embodiment of the tubular spacer1206, wherein the sleeve tails 1208 and 1210 are fixed to an innersurface 1216 of the tubular spacer 1206, for example, by gluing orheating.

FIG. 14 depicts another illustrative embodiment of the tubular spacer1206, in which the spacer 1206 is formed from the same or a similarplastic materials as the sleeves 1202 and 1204, such as, for example,polyethylene. The sleeve tails 1210A and 1210B extend from the proximalend 1218 of the tubular spacer 1206. Once the sling assembly 1220 andthe spacer 1206 are correctly positioned, the medical operator removesthe sleeves 1020 and 1204 from about the sling 1216. In this embodiment,the sleeve tails 1210A and 1210B couple to the tubular spacer 1206 by,for example, heat sealing. The physician grasps the sleeve tails 1210Aand 1210B and peels the sleeve tails 1210A and 1210B apart, as indicatedby arrows 268.

As depicted in FIG. 15, in peeling apart the sleeve tails 1210A and1210B, the soft plastic tubular spacer 1206 is separated into a portion1206A and 1206B. By grasping the distal ends 1220A and 1220B of thesleeves ends 1210A and 1210B, the physician removes both portions of thenow separated soft plastic tubular spacer 1206A and 1206B, and thesleeves 1202 and 1204 from the patient's body, leaving behind the sling1216 in the patient's body.

Additionally, it should be noted that Applicants intend any operableembodiments existing between the systems, methods, devices, andapplications thereof herein incorporated by reference and theillustrative embodiments described above to be considered within thescope of the inventions disclosed herein and, as such, claimable subjectmatter. The spacers as previously described may be made in variousconfigurations and from various materials suited to the application inwhich they are used, so long as the spacer functions to create a spacebetween the sling and the portion of the sleeve to be separated forremoval, thereby decreasing the chance of damaging the sling duringsleeve removal. Also, spacers of the invention can be colored so as toenhance visibility in the body and its location along the sleeve so asto provide a visual indicator of approximately the midpoint of the slingso as to facilitate proper placement of the sling in the body.

Variations, modifications, and other implementations of what isdescribed herein will occur to those of ordinary skill without departingfrom the spirit and scope of the invention. Accordingly, the inventionis not to be limited only to the preceding illustrative description.

1. A spacer for positioning a portion of a sleeve away from a portion of a sling at least partially enclosed within the sleeve, wherein the spacer at least partially encloses the portion of the sleeve that is spaced away from the portion of the sling.
 2. The spacer of claim 1 wherein the sleeve comprises a first sleeve having a first sleeve end and a second sleeve having a second sleeve end, wherein the first and second sleeve ends are spaced away from the portion of the sling.
 3. The spacer of claim 1 wherein the spacer comprises a tube having a lumen extending therethrough for traversal of the portion of the sleeve.
 4. The spacer of claim 3 wherein the tube has a first end and a second end and a first tube portion and a second tube portion, wherein the first and second tube portions are formed into a V-shape.
 5. The spacer of claim 4 wherein the tube includes an aperture at a vertex of the first and second tube portions for passing the portion of the sleeve in and out of the tube during traversal so as to form a sleeve bridge between the first and second tube ends.
 6. The spacer of claim 4 comprising a truss extending between the first and second tube portions.
 7. The spacer of claim 3 further comprising an anchoring mechanism for anchoring the spacer to the sling.
 8. The spacer of claim 7 wherein the anchoring mechanism is a suture.
 9. The spacer of claim 1 comprising a sling engaging member for engaging the sling.
 10. The spacer of claim 9 comprising a tissue spacing member for spacing the sling away from a patient's tissue.
 11. The spacer of claim 10 wherein the tissue spacing member has a concave surface.
 12. The spacer of claim 9 comprising an indicator for indicating a direction in which the spacer is to be removed.
 13. The spacer of claim 12 wherein the indicator forms a handle having an arrowhead shape.
 14. The spacer of claim 9 wherein the sling engaging member comprises a sling slot.
 15. The spacer of claim 14 wherein the sling slot comprises an anchoring mechanism.
 16. The spacer of claim 15 wherein the anchoring mechanism comprises teeth.
 17. The spacer of claim 16 wherein the teeth are tapered.
 18. The spacer of claim 15 wherein the anchoring mechanism comprises a cantilever beam.
 19. The spacer of claim 18 wherein the cantilever beam has an inverted T-shape.
 20. The spacer of claim 14 wherein the sling engaging member comprises a pin extending from the spacer.
 21. The spacer of claim 20 comprising an elongated shaft extending between the pin and the sling engaging member and including a channel for traversal by the sleeve.
 22. The spacer of claim 21 wherein the sling engaging member is substantially V-shaped.
 23. The spacer of claim 1 comprising a sleeve engaging member for traversal by the portion of the sleeve.
 24. The spacer of claim 23 comprising an elongated shaft extending between a sleeve bridge formed by the sleeve engaging member and the sling and including a channel for traversal by the portion of the sleeve.
 25. The spacer of claim 24 wherein the sleeve engaging member is substantially U-shaped for forming the sleeve bridge.
 26. The spacer of claim 1 wherein the spacer comprises a handle for facilitating removal of the spacer by a medical operator.
 27. The spacer of claim 1 comprising a receptacle for traversal by the portion of the sleeve and an insert for mating within the receptacle and holding the portion of the sleeve in place within the receptacle.
 28. The spacer of claim 27 wherein the receptacle is substantially U-shape.
 29. The spacer of claim 1, further comprising an aperture.
 30. The spacer of claim 1, wherein the portion of the sleeve is positioned within the spacer such that cutting a cross-section of the spacer releases the portion of the sleeve that is enclosed within the spacer.
 31. The spacer of claim 1, wherein the spacer has first and second sides, and the portion of the sleeve is at least partially enclosed between the first and second sides.
 32. The spacer of claim 31, wherein the spacer is closed along a top edge and open along first and second intermediate edges.
 33. The spacer of claim 31, wherein a bottom edge of the spacer is bonded together, and wherein the bottom edge is bonded to a section of the portion of the sleeve.
 34. A sling delivery system, comprising: a sling assembly comprising an elongate sling and a sleeve covering at least a portion of the elongate sling; and a spacer for positioning a portion of the sleeve away from a portion of the sling at least partially enclosed within the sleeve, wherein the spacer at least partially encloses the portion of the sleeve that is spaced away from the portion of the sling.
 35. The sling delivery system of claim 34 wherein the sleeve comprises first and second ends and the spacer is positioned intermediate to the first and second ends.
 36. The sling delivery system of claim 34 wherein a mid-length portion of the sling is devoid of covering by the sleeve.
 37. The sling delivery system of claim 34, wherein the spacer at least partially encloses the portion of the sleeve.
 38. A sling delivery system, comprising: a sling assembly comprising an elongate sling and a sleeve covering at least a portion of the elongate sling, wherein the sling comprises first and second sides and the sleeve comprises first and second sides; and a spacer for positioning a portion of the sleeve away from a portion of the sling at least partially enclosed within the sleeve, wherein the spacer is disposed between the second side of the sling and the second side of the sleeve.
 39. The sling delivery system of claim 38 wherein the first side of the sleeve comprises a discontinuity.
 40. The sling delivery system of claim 38 wherein the spacer creates a loop in a mid-length portion of the second side of the sleeve.
 41. The sling delivery system of claim 40 wherein the loop comprises a sleeve bridge.
 42. A sling system comprising: a sling, a sleeve covering at least a portion of the sling, and a spacer, wherein the sleeve comprises first and second sides, the first side having first and second slit-shaped apertures intermediately located between first and second ends of the sleeve, the sling threads out of the sleeve through the first slit-shaped aperture and back into the sleeve through the second slit-shaped aperture creating a mid-length sleeve loop, and the spacer is positioned to space the sling away from the mid-length sleeve loop.
 43. The sling system of claim 42 wherein the spacer is a tube and wherein the sleeve loop is partially secured within the interior of the tube.
 44. The sling system of claim 42 wherein the tube is substantially flat.
 45. The sling system of claim 44 wherein the substantially flat tube comprises an aperture for sighting a cutting line through the spacer and sleeve loop to separate the sleeve into portions that may be removed from about the sling. 